Abstract 185: Safety and Outcomes of Intravenous Thrombolysis (IVT) in Dissection-related Ischemic Stroke: An International Multicenter Study and Comprehensive Meta-analysis of Reported Case Series

Abstract

Background&Purpose: The safety and efficacy of intravenous thrombolysis (IVT) in dissection-related ischemic stroke (DRIS) has not been established. We sought to determine safety and recovery rates of IVT in DRIS using prospective, international, multi-center data and by conducting a comprehensive meta-analysis of reported case-series. Subjects&Methods: We analyzed consecutive DRIS patients treated with IVT according to national guidelines during a five-year period (2009-2013) at seven tertiary-care stroke centers. Pre-treatment NIHSS and modified Rankin Scores (mRS) at discharge were documented. Symptomatic intracerebral hemorrhage (sICH) was defined as imaging evidence of ICH with NIHSS increase of 4 or more points. Functional independence (FI) and favorable functional outcome (FFO) were defined as mRS 0-2 and 0-1. Recanalization of intracranial vessels was assessed using TIBI criteria. We also conducted a systematic review and meta-analysis of all available case-series reporting safety outcomes in IVT-DRIS using PRISMA guidelines. Results: A total of 39 DRIS patients (mean age 60±18 years; 59% men; Caucasians 51%, blacks 36%, Asians 13%; median NIHSS 13 points, IQR 9-17) received IVT. sICH, in-hospital mortality, complete recanalization, FFO and FI were 0% (adjusted Wald 95%CI: 0%-8%), 10% (3%-24%), 55% (40%-70%), 61% (45%-74%) and 68% (52%-81%). The pooled sICH and mortality rates in our meta-analysis including 10 case-series (234 IVT-DRIS patients) were 2% (0%-5%) and 4% (0%-8%). The pooled recanalization, FFO and FI rates were 45% (26%-67%), 41% (29%-54%) and 48% (61%-72%) respectively. We documented no heterogeneity (I squared statistic < 45%, p > 0.1 for Cohran Q test) between case-series reporting estimates of sICH, mortality, recanalization and FI. There was substantial heterogeneity for FFO (I squared statistic=61%; p=0.006). Subsequent meta-regression analysis identified baseline NIHSS as independent predictor of FFO (p<0.05) accounting for FFO variance across different studies. Conclusions: Our prospective, international data coupled with comprehensive meta-analysis results underscore IVT safety in DRIS while functional recovery rates compare favorably with overall IVT efficacy reported in phase III trials.